Is the American Dietetic Association Attempting to Limit Market Competition in Nutrition Counseling?

[Disclosure: My wife is a weight loss consultant whose work could conceivably be seen as competition to Registered Dietitians. Also, as I have written about extensively in this piece for Forbes detailing my own journey overcoming Bipolar II, I have been a longtime consumer of holistic nutrition counseling services, from people who are not RDs. It was my connection to these services described in my previous article, as a longtime consumer, which alerted me to possible attempts to limit my--and your--free choice as a consumer.]

Deep within the annals of obscure amendments to state licensure statutes, and within the US Patent and Trademark Office’s records, a battle is raging which could have a massive impact on the way you access nutrition information in our nation’s healthcare system.

Here’s the outline:

Through a series of bills it is supporting and lobbying for, the nation’s professional association of dietitians, the Academy of Nutrition and Dietetics—generally known to the public by its old name, the American Dietetic Association—appears to be gaining legal control over who may provide nutrition counseling in a professional context. The effort also extends through a series of certification trademarks for which the Academy has recently applied.

This past January, the group, founded in 1917 and known for almost a century as the American Dietetic Association, announced it was changing its name to the Academy of Nutrition and Dietetics. (I use the old and new name equivalently in this article.)

Last December, before it announced its name change, the Association applied with the US Patent and Trademark Office for a series of certification marks, a type of trademark related to credentialing, for a comprehensive array of nutrition-related professional titles, including:

Certified Nutrition Associate

Certified Nutrition Coach

Certified Nutrition Educator

Certified Nutrition Manager

Certified Nutrition Professional

Registered Nutrition Associate

Registered Nutrition Coach

Registered Nutrition Educator

Registered Nutrition Manager

Registered Nutrition Professional

The certification mark applications, in conjunction with the name change, suggest that the Academy is attempting to expand its scope and influence, from its decades-old role as the industry group for Registered Dietitians (RDs, who often work in institutional settings such as schools and hospitals), to now touch upon the entire field and professional practice of nutrition.

Indeed, an internal American Dietetic Association document, entitled “Regulatory and Competitive Environment of Dietetic Services,” appears to imply a strategy for gaining legal control over the term “nutritionist,” as a path to limit competition for its members, against competing types of nutrition counseling.

[UPDATE 4/9/12: A reader alerted me that the link above, which originally led to a copy of the document posted on the Washington State Academy of Nutrition and Dietetics website, stopped working days after my article came out, and now returns a Page Not Found notice. I am working on a follow-up article to determine why the Washington State AND took the document down after my article generated press attention and public discussion about it.]

[UPDATE 4/10/12: Yesterday I sent representatives from the national office of the Academy the following email:

I find it quite a coincidence that this happened to be taken down days after the first major media coverage of the document.

I have a few questions for your comment:

Did you or anyone in the national AND office issue any directive to take that document down?

If so, why did you want the document taken down?

If not, who was responsible for taking it down, and why did *they* want the document taken down?

If the reasons for the document being unavailable are merely technical (server overload, etc.) would you be willing to ensure that the document gets reposted, so full public discussion of the document may continue?

I sent a similar email to the Washington State chapter of the Academy. Today I received an email from the executive director of the Washington State chapter, informing me that the document has been restored. Thank you, Washington State AND, for restoring it. No comment yet on any of my questions, from either the national or Washington State chapter. I'll let readers speculate as to why it might have been taken down after my article was published.]

While no one would deny that Registered Dietitians often provide extremely valuable nutrition services across a wide range of settings (in schools, hospitals, and corporate workplaces, to name a few typical places), this article is not about Registered Dietitians per se.

Rather, I focus here on the professional association that represents them politically, and particularly, on its apparent efforts to protect RDs against marketplace competition from other nutrition professionals. The article raises the question: should consumers have access to a wide array of different nutrition counseling choices/philosophies, among a wide array of professionals with differing credentials, or should the American Dietetics Association have strong legally-enforced say in who may or may not compete with the specific group of nutrition professionals it represents?

The American Dietetic Association’s Anti-Competition Document

The Association document linked above minces no words about its purpose. It opens: “This Backgrounder highlights the significant competitive threat Registered Dietitians. . . face in the provision of various dietetic and nutrition services. . . . We must be aware that existing legal and regulatory constraints on practice are unlikely to prevent robust, broad competition in these growth areas.” [Emphasis added.]

The document specifically bemoans that the word “dietitian” (the professional association’s decades-old area of coverage and speciality) is regulated far more heavily than the word “nutritionist”:

Simply put, governments more strictly regulate the work of and qualifications for dietitians than it does for nutritionists, and competitors are explicit about their intention to exploit this dietetics/nutrition distinction. An array of competitors is already providing would-be clients with personalized health education and nutritional counseling in growth areas such as prevention and wellness and in private practice careers. The required and necessary skill set of RDs competing with these other nutrition professionals may not necessarily be the same that clinical dietitians [sic], but RDs cannot cede this expanding market to others who clearly intend to provide nutrition services. [Emphasis added]

The document goes on to survey in detail the competitive threat posed by many different types of non-RD practitioners who give nutrition advice:

Nurses: The document worries that “‘Wellness Nurses’. . . are more likely to compete with RDs; they largely work in local government, corporate offices, and schools, where they conduct health coaching. . . and other tasks that could otherwise be performed by a community or consultant dietitian.”

Pharmacists: “Research shows that pharmacists are frequently providing information about healthful diets, medical device functions, and numerous other issues raised by customers. The potential for competition from these consultations arises if, after successfully screening a man for diabetes, the pharmacist were to talk with him about changing his diet in light of his diagnosis as diabetic.”

Personal Trainers: The document states that “the emphasis on preventive health and wellness care is expected to drive an increase in the number of jobs for fitness professionals,” and decries that “continued competition can be expected” from them. “[B]ecause of their current practice and expressed intent, trainers should be considered competitors for certain unrestricted preventive and wellness care tasks.”

Naturopaths and Homeopaths: “Alternative practitioners like naturopaths and homeopaths are among the professions most aggressively seeking greater recognition and acceptance by advocating and defeating legislation. It is the group of traditional naturopaths wanting to provide nutritional counseling (and who are closely aligned with holistic medicine and nutrition community) that pose one of the most significant competitive threats to dietitians in the marketplace.” [Emphasis added.]

Finally, the Academy seems to outline a strategy to prevent the competition: gain legislative control over the term nutritionist: “A troubling pattern exists when looking at practice exclusivity and title protection in the most populous states, particularly with regard to non-licensed practitioners’ use of the title ‘Nutritionist.’ None of the three states largest in population protect the title ‘Nutritionist.’”

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I can see the level of pride and emotions that come from some of these posts. I ask that we are able to step back, and look at this situation rationally, clearly and fairly.

Comparing credentialed nutrition professionals to MDs, RNs or Dentists is like comparing apples to watermelons. A % of RDs and most other credentialed nutrition professionals are not going to perform invasive procedures, nor handle acute health or emergency care cases. Therefore, we should compare them in a more fair context.

We should begin by considering that just as there are different medical doctor philosophies of practice (MD, DO or ND) and there are different levels of nurses (LVN/LPN, RN (3 degree levels), NP, etc), the same is true with credentialed nutrition professionals. While there could be some sort of heirachy system based on education and scope of practice (i.e. RDs supervise DTRs), there are also nutrition professionals that could practice on the same level (i.e. RD, LN, CCN, CNS), but may not necessarily chose to practice in the same fields of nutrition (and there are many fields). This is also where the new trademarks come in from AND, however, this shouldn’t discount the other credentials from nutrition associations that are working hard to set standards of education and scopes of practice (a box that can widen with time and education). Yet, have any of you visted their websites (some of mentioned in a prior post) to see what they are trying to accomplish?

Supposedly the field of “nutrition science” and it’s therapeutic application (i.e. nutrition education, nutrition assessment, nutrition counseling) begain in the 1980s. Yes, this is certainly far from when AND was initiated in 1917, but “science is always changing, never exact” and with the incorporation of Nutrigenomics and Functional Medicine, this is proof of the realization of how important and powerful foods and the nutrients they contain are! I have respect for what AND has done initially for the health of this country when there was no one or nothing else. However, AND and ACEND were not recognized by the Department Of Education until 1974, and the RD credentialing body of CDR by NCCA until 1980! I believe state licensure efforts have been in effect for over 20 years? Therefore, it took them quite a while to get where they are today. It will take some time for these nutrition associations to gain just as much respect, but again, they are working hard to do so.

There are more nutrition professions out there that “knows what they are talking about” in the fields of food and nutrition science. Give these other “new” associations or credentialing bodies (ANFP, ACBN, HNCB, CBNS, CBNC), that were established between 1960 – 2003, a chance to further establish themselves, and we may be quite surprised at how they may help progress the profession…

What’s the difference between a family practice physician and a chiropracter? A physical therapist and a personal trainer? A dietitian and a nutritionist? Expertise, schooling, required continuing education, and yes, it should be reimbursement through insurance, government agencies and the like.

Unfortunately, legislation is not helping secure the role of the health professionals as the provider of services in nutrition due to some mis-steps several decades ago, which would have created better medical nutrition treatment definition. Don’t fool yourself that these other medical practitioners aren’t continually paying for representation to protect their role as the expert, both for their practice and the continued assurance of quality for their patients.

Does a consumer really understand where medical treatment ends and helpful neighborly advice begins? Dr. Moms have been practicing medicine for years, that doesn’t mean that she should be given a prescription pad and allowed to fill in when your dad’s having chest pain, because she’s “Raised 5 kids and they’re doing all right.”

She can now jump online and in the time it takes to make an afternoon snack, presto, she’s a nutritionist. I think this should be un-nerving to any and all consumers. Due to the health of people in our world, it’s rare to come across a person I’m coaching whose health history is medically uncomplicated. I’ve had so many clients whose health has been put at risk by well meaning friends, family members and those who know just enough to be extremely dangerous.

There are certainly legitimate, complementary medicine practitioners, though there is little ability for consumers to sort out the well schooled from the Slippery Petes. I would love to see better clarification of these roles so that their work can be done in cooperation instead of competition with sound nutrition practices. At this point, it’s difficult to know what backgrounds are real and what are internet creations. I hope more definition of these roles does occur in the future for the benefit of all persons.

The Hospital’s Head-Dietitian came to my late husband’s room to counsel him because I was bringing his food in. He told her he was diabetic and he was being served food that he couldn’t eat. We count carbs, not sugar, she countered. His first ‘diabetic’ meal was BBQ-Sauce and fatty pork on a white hamburger bun and a large square of white cake with that whipped shortening and sugar frosting. That’s it. She was hugely obese. She finally left the room when my gentle, buddhist husband told her, “Why would I take nutritional advice from someone who looks like you?” The very idea that to be able to purchase nutritional supplements, I would need to pay for an appointment with one of this hypocritical, under-educated, self-important bimbos … and people STILL want to vote for ‘big business’ over ‘the average working stiff’? EXCELLENT ARTICLE. Thank you.

I just recently graduated with a Masters degree in acupuncture. I had classes in both Western and Eastern nutrition as part of my education. The Western books, written by RDs and endorsed by the ADN provided almost laughable advice as far as nutrition goes. In fact, their current advice isn’t as good as the Eastern advice from 2,000 years ago. Don’t believe me? Have you visited anyone in the hospital recently and seen what RD-approved menus are like? They’re still serving up canned, processed industrial waste. You’re hard pressed to find any food on the menu!

The people behind this move need to come clean and admit that this is all about the money. You can be that somewhere in the ADN files there is a document that says if we can get everybody else out our field (eliminate the competition), we’ll make a lot more money. Everything else — concern about the public, concern about the quality of other practitioner’s advice, etc. — is just a smoke screen. It’s just a shame in the Land of the Free, that are legislators are so willing to go along with charades like this.

A previous responder compared RDs to MDs. I’m glad she made the comparison because a little research into the history of the AMA shows exactly what they were all about, i.e., putting their competition out of business so MDs could make more money. And boy that strategy has worked for them. They have a monopoly on the term “medicine” and we pay the highest amount for health care in the world by about twice the per capita amount as the next country on the list. And, it isn’t working for us. I was looking at a “results” chart recently. The US is right ahead of Cuba as far as healthiness and we pay about 40 times as much. If legislators do this for the ADN, we will see the same thing in this field as well.

I find some of the passionate negativity regarding the sponsorship ties of the Academy to food companies somewhat misrepresented. Sponsorship dollars account for about 11% of the monies raised by the Academy with the bulk coming from members dues.

I also find it somewhat stunning that the same people who damn food companies somehow feel that selling supplements that have a significant profit margin as a moral high ground. I have been to sports nutrition conferences outside of those sponsored by the Academy and the supplements being sold would generate a positive drug test in the NCAA, MLB, and NFL. I have seen supplements RUIN a player’s career and hurt patients When an athlete tests positive, the consumer believes a needle was involved-do you think contaminated supplement? But somehow supplements get a pass in this discussion? So if we are to damn the Academy, why are those making a living selling nutritional supplements and not stressing whole, natural plant based foods as the first and best option, getting a pass? With the recent history with Star Caps, Metabolife and Hydroxycut as well as supplements with melamine, why is there no outrage there? Gary Null’s Power Meal? Ring a bell? Look it up? We embrace supplements. Why? Because they are natural? In many cases, they are no more natural and as insidious as refined high glycemic grains-yet no outrage from the groups selling those. So if we are talking full disclosure-let’s have real full disclosure.

I agree with you that the focus on that 1% contribution from the food industry and other corporate sponsors may be taken to the extreme, but we know how powerful lobbyists are. Of course, there are some nutrition associations, that accept sponsorships from laboratory testing facilities, pharmaceutical grade supplement companies and natural food manufacturers (a healthier step up from *some* of AND’s sponsors). However, there are nutrition associations that do not accept *any* sponsorship from corporations. So we must not make assumptions about any individual or organization until we know more about them.

In turn, just as there is plenty of passion about the misconceptions about the role of dietitians and where they do and do not work, the same can be said for credentialed nutrition professionals. Yes, there are way too many programs out there trying to education people on nutrition, agreed! That said, there are programs leading to certificates, diplomas and degrees, that may culminate in the ability to get certified through 1 of the 4 nutrition credentialing bodies I mentioned in a prior posting (and of course there are others that are/is working toward legitimacy) and those are the ones that I am thinking of when I say “credentialed nutrition professional”.

There are some nutrition programs created by RDs and MDs that utilize the word “nutrition” or “nutritionist” in the professional’s title. However, usually, they push programs and software that allow you to legally practice, because the RD is your supervisor (even if you are 5 states away). This is acceptable because as long as you educate and practice the curriculum and methods created by the RD, you are working within most state licensure exemptions. So as you can see these nutrition professionals (that may not have any health, science or nutrition background prior), are working within a set scope of practice and usually have a code of ethics they must follow. I’m not too thrilled with this, but it is allowed by law and again, they do have limitations on their scope of practice.

We shouldn’t go too deep into discussing supplements because, then we’ll have to talk about the dangers of medication, the side effects, the nutrient deficiencies and how a percentage of them are “band-aids” not actually working on supporting the body toward healing and optimal health. The incidences that you mentioned are the reason why the FDA regulates supplements. Yes, they are regulated, just as pharmaceuticals are, but of course we know that the FDA does not have sufficient resources to do a thorough job in either of these categories, and then some.

Also, I will quickly say that a percentage of nutritionists sell supplements and percentage do not. There’s definitely a fine line here when any practitioner sells products, but again, this is where their signed code of ethics comes into play. I can say that I personally know more integrative doctors, integrative nurse practitioners, integrative psychiatrists, medical NDs, traditional NDs (missing medical training, sometimes clinicals), credentialed nutritionists, etc. that send their clients out to a drugstore or health food store to purchase the supplements that they’ve been prescribed (instead of medication). Whole, organic, clean foods is definitely the first step; however some people need additional support, hence supplementation. MDs, RNs, NPs, RDs, Credentialed Nutritionists and other licensed health care practitioners know this and incorporate elements of functional medicine into their practice. Functional Medicine is the future!

I appreciate the discussion about the food industry, lobbyists and supplements. I agree that perception becomes reality for many. As a member of the Academy and an RD, does anyone really think that I would recommend soft drinks because they provide sponsorship dollars. What other beverages does Coke market and sell-yes, they make an organic green tea that I bet many people didn’t realize that was a Coke brand.

Supplements are not regulated by the FDA in the same manner as drugs as there is no pre-market approval and you have to have a license to prescribe drugs-but not supplements. ie MD, NP, PA. I would also agree that not all practitioners sell supplements. However, I did testify in Austin Texas for the practice act and was in the room listening to the testimony from those opposing. The supplement industry was heavily represented. So as we damn food manufacturers and the sponsorship they provide, I think a flip of the coin is worth the disucussion

Oh Roberta, I get it now! Yes, just like there are over-the-counter pharmaceutical drugs, there are also over-the-counter dietary supplements. Just as there are prescription drugs, there are also prescription level dietary supplements.

There are not a lot of natural or integrative pharmacies, such as Pharmaca, where one can purchase a prescriptive level supplement they are interested in or their doctor prescribed, so they may also go online and purchase from a web retailer that must have a licensed health care practitioner on board. Otherwise, yes, the way to control how one gets access to these prescription level dietary supplements, is via a licensed health care provider!

What would be considered a drug in Europe may be considered an OTC dietary supplement here. However, that doesn’t mean that those dietary supplement manufacturers, and others, take any shortcuts. They still regulate their product as if it were a drug, running the necessary clinical trials, testing batches, and following other good manufacturing practices (cGMP). If there is something that is currently an OTC supplement that the FDA deems prescriptive level, it does get pulled off vitamin and health food store shelves and then can be only be found through a licensed health care practitioner.

So this is why homeopathic and oriental medicine doctors will sell supplements or formulate one for you, since herbal medicine and homeopathy is an art and can be tailored to the individual. They and other practitioners: MD, ND, licensed nutritionists, etc. may also sell prescription supplements, that may or may not be private labeled (for practitioner “loyalty”, just as aestheticians do), but if clients are smart, they can always find those “private label” brands online or on store shelves (if not deemed prescriptive level), for less! Although I will say that just as some practitioners will sell lab tests for below retail price, the same goes for supplements. Not everyone is out to make a “quick buck,” (that’s another story involving many players in countries around the globe). They are usually in it to help support the optimal functioning and health of their clients.

The comparisons made in some of the comments here between the certifications that MDs must receive and those RDs receive are just absurd. Tools of Big Pharma and Big Ag, whether considered together or separately, have little or nothing that I would ever want. I avoid both like the plague. Which means I try to stay healthy.

If I wanted to eat frozen peas, HFCS-laden Coke or Pepsi and the homogenized/pasteurized puss that passes for commercial dairy these days, I might go to an RD for advice. But as it happens, I’m not stupid.

When I have needed help that was not of the emergency medical kind, I have sought out the services of an ND, and have been very happy for it.

I would lose all respect for the RD profession if the ADA/AND prohibited my ND from practicing in my state. That would really piss me off.

On behalf of the National Association of Nutrition Professionals (NANP), a nonprofit professional business league representing the interests of holistically-trained nutrition professionals, I want to thank you for writing this article. The AND is attempting to convince the American public that the only professionals who are qualified to provide nutritional counseling are Registered Dietitians (RDs). However, there are organization like ours, who uphold strict quality guidelines. The NANP reviews and approves holistic nutrition education programs based on our strict educational standards. Additionally, we offer a Board Exam in Holistic Nutrition, and only qualified individuals can become Board Certified in Holistic Nutrition®. We are hopeful that your article will start a dialog that educates Americans about other types of nutrition professionals, in addition to RD’s, who are qualified and capable to assist consumers in creating health and well-being through diet and lifestyle adjustments.

Michael, this is not the first time that the ADA has tried to bully people. Last year I posted a letter to my organization’s (the National Association of Nutrition Professionals’) LinkedIn page, that notified our page members of the legislation the ADA had put forth in several states. I received a letter from the ADA, warning me that they had become, “aware of various misrepresentations” I had made in that letter regarding their attempts “to take away the right to practice nutrition unless you are a Registered Dietitian.” The letter went on to state, “To the contrary, through legislation, ADA seeks to ensure that practitioners, be they nurses, physicians, RDs or other nutrition professionals have met minimum education and experiential requirements. The legislation does not require the RD credential, but individuals who have received the RD credential do meet the requirements of the legislation.” Of course they do – because the requirements are that of RDs and were inserted into the legislation by the ADA or the applicable state Dietetic Association. The letter concluded with the following threat, “Please correct the misstatements as soon as possible and refrain from making future misrepresentations. ADA will take action as necessary to correct disparaging and untruthful representations.” Our organization has been bullied, and now they are attempting to bully you and Forbes magazine.

Good article. I’m a registered dietitian and a member of the AND. I work as a clinical dietitian and my JOB is medical nutrition therapy. It seems quite unfair for individuals with PhD’s/MS’s in the science of nutrition to be limited within their practice. As I’m sure many RD’s would agree, these people are not the problem. It’s the individuals giving nutrition advice and/or medical nutrition therapy that are not educated on the metabolism of nutrients, nutrient and drug interactions, and disease states that benefit from nutrition therapy. Read this outloud with me: “MEDICAL… Nutrition… THERAPY”. The science of nutrition is complex and individuals without proper education giving out nutrition advice/counseling is potentially quite dangerous. Personal trainers, individuals that got some online certificate in nutrition etc etc NEED to understand the implications of many diseases on the body, medical treatment modalities for these diseases/conditions AND the NUTRITION therapy involved. Medical Nutrition Therapy (MNT) is treatment/management for a medical condition with nutrition. The education is comprehensive for RD’s and very few other professions cannot claim this. If you look at some of the major disease states in our country – Diabetes, Chronic Kidney Disease, Heart Disease… the treatment is individualized and depends highly on ones past and current health history. I doubt a personal trainer knows that he shouldn’t be recommending banana’s and orange juice to someone with chronic kidney disease. But why? Those are healthy foods! A monkey could tell you that. Healthy foods, high in potassium. Good for may people, bad for people on ACE inhibitors/ARB’s and with CKD that have proven to be a higher risk for hyperkalemia. An elevated potassium level in their blood could cause cardiac arrest. I run into SO many patients that have gotten the wrong nutrition advice/counseling from even practicitioners you’d think were qualified to provide it (cough, chiropractors, cough cough). People think nutrition advice is just “eat this healthy food in this combination. Try this recipe. Eat less calories”. It’s not. I’m tired of my patient telling me things like “my nutritionist told me that grapes are negative calorie foods” or “my chiropractor sent me to a homeopathic nutritionist, they tested my hair and told me I have a copper/iron toxicity and to stop eating foods with these in them” and my favorite “I need these 30+ supplements that my chirapractor (and other professions known for doing this) said I should be taking, but it costs over $100/month. That’s nutrition advice that’s not EVIDENCE based or taking into account all the patient’s past medical history and lifestyle. No one in this country should be practicing medicine unless they are going by evidence based studies. Giving out nutrition advice is okay to individuals that don’t have tender medical histories. Weight loss counseling certifications/nutrition advice should be okay for these people. But when it comes to MEDICINE, you shouldn’t be allowed to read a book and think you’re an expert. So you know a lot about insulin and diabetes… where are your credentials and education to prove it? We are thinking of the health of the patient when we would say that tighter liscensure/credential for MNT should happen. Physician’s do NOT refer their patients to personal trainers/chiropractors…. they refer to RD’s. No one wants to see qualified people not be able to practice what they went to school for 6+ years. Not all professions are able to provide advice that’s best for the patient. I think the AND is trying to weed out the ones not qualified for providing SOUND nutrition/medical advice. People are wasting money and their health is at stake. The end goal is not a monopoly but the RIGHT nutrition being practiced. I certainly hope that everyone QUALIFIED for practicing MNT can continue to do so.

“Is the American Dental Association Attempting to Limit Market Competition in Dentistry?” “Is the American Medical Association Attempting to Limit Market Competition in providing medical care?” Both of these fake headlines are as ridiculous as the one written by Michael Ellsberg. RDs are experts in their field just attempting to legally obtain the rights to the titles they deserve.